Insurance
FAQs

Spa Creek Dental is considered an out-of-network provider and we will be happy to bill a claim to your insurance company if your plan offers out-of-network benefits. Spa Creek Dental is not in-network with insurance plans and is not a Medicaid or Medicare provider.

It means that we are not an “in-network” provider. Insurance companies have control over the fees of “in-network “providers. Since we don’t want them to control what we offer, we do not participate as an in-network provider for any insurer’s networks. Many insurance companies do provide coverage for out-of-network providers like us, but it is often limited, and we would have to do some research to get an estimate of what the coverage would be.

One of the best ways to gain access to see any dentist is to find a PPO dental plan that offers the highest out-of-network rates. These dental plans are sometimes classified as Full Coverage plans, Open Choice, Open Access, or Indemnity plans because they will pay a UCR (Usual Customary and Reasonable) type of payment or their “allowed amount” for out-of-network claims. HMO plans are through managed healthcare organizations and do not offer out-of-network coverage.

UCR fees are the standard fees that the insurance company gets to set for what it will reimburse providers. Insurance companies will determine a maximum amount that they will “allow” providers to charge for services. Any remainder beyond the “allowed” amount will then be charged to the patient. The price is specific to the insurance policy. Another policy with the same insurance company could set a totally different price. Allowed amounts can vary not only by policy, but also the location of the healthcare provider, their license type, and other factors.

Typically, insurance companies want to incent patients to go to in-network providers, and so insurance carriers will cover a significantly lower portion (aka “co-insurance %”) of the “allowed” amounts when they reimburse out-of-network providers like ourselves. As an example, an insurance company may have an allowed amount of $100 for an in-network service but will only cover 10% if that same service is provided by an out-of-network provider, leaving the patient responsible for the remaining $90. Therefore, patients are often surprised at how poor their coverage is, when they learn that their insurance company’s co-insurance for out-of-network is a fraction of what they are used to with in-network providers.

Many policyholders only think about the cost of medical services after the service is provided and can be caught off guard when their insurance doesn’t cover all expenses. To mitigate the possibility of a big bill, policyholders should always check with the provider to learn if they are in-network, and to understand if there will be a remainder that they could be responsible for, if the insurer does not cover all services.

When a claim is billed to insurance, they first determine whether the care is covered by the policy. If it is, the claim is then processed. The insurance will look up the amount they will allow for each CDT code on the bill based on the healthcare provider you saw and other variables. This price is then used to calculate either the amount applied to your deductible or how much money you will be reimbursed based on your co-insurance. If your co-insurance is 50% and your deductible has been met, you will be reimbursed 50 % of the allowed amount set by your insurance, not 50 % of the amount you actually paid.

For example, a patient is seen for a Comprehensive Oral Exam and $119 is billed to the insurance. If the insurance plan allows $100 for the exam and the coinsurance is 50% for in-network providers, the insurance will pay a maximum of $50 for the exam. (Providing the deductible has been met, if applicable, and the max benefit limit has not been reached.) The remaining balance of $54 would be the patient’s responsibility as determined by the insurance and the patient would be balance difference.

If, however, the insurance plan only offers a 10% co-insurance for out-of-network providers, then the insurance company will pay a maximum of $10 for the exam, and the remaining $109 will be invoiced (“balance billed” to the patient.)

One other note about allowed amounts: insurance companies usually will not disclose their allowed amounts to out-of-network providers until after the services have been provided. This makes it very difficult for providers to accurately estimate the out-of-pocket expense prior to the services being rendered. Out-of-network provider offices must often wait for multiple hours just to get an estimate on what the co-insurance will be, and still may not be given the allowed amount – making it a real challenge to get the most accurate estimate possible.

Because we are an out-of-network provider, insurance companies will not easily disclose their reimbursement rates to us. Since each plan may be different in what its allowed amounts, deductibles, and co-insurance rates may be, we typically need to call in to the provider hotlines to get an estimate. This process can take hours of time on the phone, and we often must wait multiple days to be sent an estimate.

Additionally, the estimate that is sent to out-of-network providers doesn’t usually include the allowed amount, so even after getting a response from the insurance, we typically have to guess what amount they will cover of services, making us unable to give a 100% quote on what the remainder billed to the patient will be.

One of the main differences with how out-of-network providers handle insurance payments is known as balance billing. In-network providers agree to accept an insurance company’s fee schedule and reimbursement amounts for each procedure. But because out-of-network providers have not agreed to any specific amounts, they are allowed to bill for the additional charges not covered by insurance, as in most cases, the insurance payment is not sufficient to cover the cost of services rendered.

Health insurance claims can be confusing. Many people are caught by surprise when they learn that their health insurance does not pay them back based on the amount they pay for care but the amount their health insurance believes the care should cost.

One of the best things you can do to help keep tabs on your healthcare costs is to take good, thorough notes and to be knowledgeable when it comes to your insurance benefits. Some things to consider asking when your insurance company are:

1. What is my financial responsibility?
2. What is my out-of-network (OON) deductible?
3. What is my out-of-network (OON) cost share? (The percent you are responsible for)
   5. What is my out-of-pocket maximum and how much is remaining?
4. Are there any limitations and frequency restrictions on certain procedures?
5. Is there a waiting period before certain procedures will be covered?
6. Are there any exclusions to my insurance plan? Some plans have what’s called a “missing tooth clause” which means the insurance will not cover the costs of replacing the tooth if the tooth fell out or was extracted before the current dental coverage started.

Traditional Medicare does not cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you're in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, even though it doesn't cover dental care.  For example, if you suffered a traumatic injury to your teeth or jaw, Medicare would cover hospitalization and procedures medically necessary for recovery.